70 year old male with AKI

-

 I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan

NAME:- G VISHAL

ROLL NO :- 50

70 year old male patient farmer by occupational resident of nalgonda is bought to casuality with the cheif complaints of abdominal distension ass with abdominal pain since 20 days

Fever since 20 days

Facial puffiness since 20 days 

Breathlessness since 20 days

History of present illness:- patient was apparently asymptomatic 40 days back then he started having alcohol (360ml 4times a day)and associated with decreased food intake and after 20days he complains of abdominal distension which is insidious in onset gradually progressive which is associated with abdominal pain and pain increases with food intake and spontaneously reduces after some time.

Fever since 20says associated with chills and rigor relieved on taking medication and is not associated with cold, cough burning micturation.

Facial puffiness since 20days .

Breathlessness since 20days(gradeII to grade III mmrc) no seasonal and diurnal variation.

No complains of burning micturation constipation decreased urinary output.

Past History:

Not a k/c/o HTN/DM/EPILEPSY/TB.

History of similar complaints in the past and hospitalised for 4days

Personal History:

Appetite- Lost

Diet- mixed

Sleep - adequate

Addictions -  alcohol started at the age of 20years .stopped 3 years ago and again resumed 40days back.

Smoking started at the age of 18years stopped 3years.

General Examination:

Patient is c/c/c

No pallor,icterus,cyanosis,clubbing,lymphandenopathy,pedal edema.






Vitals:

Temp - 99.8 F

PR-112bpm

RR-24cpm

BP-130/60mmhg

SPO2-98% on RA

Systemic examination :-

Rs:- BAE+ NVBS 

P/A :- tenderness present in right hypochondrium and right hypogastric regions 

Cvs :- s1 s2 heard 

Cns :- NFND 

INVESTIGATIONS:- 








2D ECHO


CHEST XRAY PA VIEW 


ECG:- 

Usg abdomen :- 




REFERALS :- 
Surgery referal was taken i/v/o pain andomen and they advised to review usg abdomen


Provisonal diagnosis :- 

PYREXIA UNDER EVALUATION 

PRE RENAL AKI 

PAIN ANDOMEN UNDER EVALUATION 

RX :- 

1 IV FLUIDS NS @100ml/hr

2 INJ NEOMOL 1gm/iv( if temp >101)

3 INJ THIAMINE 1amp in 100ml Ns IV/BD

4 INJ MONOCEF 1gm IV/BD

5 STRICT I/O CHARTING 





Comments

Post a Comment

Popular posts from this blog

46 year old female patient with seizures

-
Image
  I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan NAME:- G VISHAL ROLL NO :- 50 Cheif complaints :-  Patient was brought with complaints of 2 episodes of involuntary movements of upper and lower limbs and hemoptysis . History of present illness :-  Patient was apparently asymptomatic then she developed sudden onset  of movements of both upper and lower limbs at 5am in the morning which lasted for about 4-5mins , not associated with any trigger, no aura and the patient was confused after the episode  she had an other similar episode while she was brought to the hospital. She had similar episodes at the hospital. Sequence of events :-  13 years ago  she developed low back ache and generalised weakness started for which she went to local hospital. Then during
Read more

Medicine blended assignment

-
Image
Medicine Assignment - May 30, 2021 May 30, 2021 I G vishal (roll no :- 42)of 8th semester have been given the following cases to solve in an attempt to understand the topic of 'Patient clinical data analysis' to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis and come up with a treatment plan. Pulmonology   A)55 Year Old Female with Shortness of Breath, pedal Edema and Facial Puffiness. Patient details:- https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html Questions 1)what is the evolution of the symptomatology in this patient interms of an event timeline and where is the anatomical localisation for the problem and what is the primary etiology of the patient  problem ? 1A) Evolution of symptomatology  1st episode of sob - 20 yr back 2nd episode of sob - 12 yr back From then she has been having yearly episodes for the past 12 yrs  Diagnosed with diabetis
Read more

LONG CASE

-
Image
  This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed  I have been given this case to solve in an attempt to understand the topic of  "Patient clinical data analysis"  to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.   HALL TICKET NUMBER: 1701006057 Name :- G vishal 40 years old Male patient  painter by occupation resident of bhongiri presented to OPD with chief complaints of            Shortness of breath s
Read more